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Indigenous Deaths in Custody: Part E Profiles: Indigenous Deaths in Custody 1989 - 1996

Part E Profiles: Indigenous Deaths in Custody 1989 - 1996

New South Wales
Victoria
Queensland
Western Australia
South Australia
Tasmania
Northern Territory
Other Deaths in Custody
Glossary


ID No

Date of Death Age

Sex

Custody Location Basic Cause

New South Wales

4NSW 25/7/89 28

M

Prison Long Bay Prison Self-inflicted
6NSW 21/10/89 17

M

Prison Maitland Prison Self-inflicted
7NSW 25/10/89 28

M

Prison Silverwater Prison (WH) Natural
10NSW 8/1/90 24

M

Prison Parklea Prison Drugs
19NSW 31/5/90 19

M

Prison Long Bay Prison Natural
26NSW 29/5/91 25

M

Prison Lithgow Prison Natural
27NSW 10/6/91 35

M

Prison Parklea Prison Self-inflicted
28NSW 12/6/91 33

M

Prison Long Bay Prison ( PHH) Natural
37NSW 5/3/92 23

M

Prison Long Bay Prison (PHH) Natural
39NSW 10/6/92 38

F

Police Macquarie Fields Police Self-inflicted
40NSW 3/7/92 14

M

Police Princes Hwy, Batemans Bay Injury
42NSW 24/11/92 43

M

Police Police Van, Moorebank Drugs
44NSW 10/3/93 64

M

Prison Cooma Prison ( PHH) Natural
46NSW 21/5/93 20

M

Prison John Moroney Prison Natural
51NSW 29/10/93 33

M

Prison Long Bay Prison Natural
52NSW 2/11/93 46

M

Prison Long Bay Prison Natural
62NSW 3/6/94 30

F

Prison Mulawa Prison Natural
63NSW 19/6/94 24

M

Prison Long Bay Prison Self-inflicted
67NSW 13/12/94 19

M

Prison Parklea Prison Self-inflicted
71NSW 15/2/95 38

M

Prison Broken Hill Prison Natural
72NSW 1/3/95 20

M

Prison Long Bay Prison Self-inflicted
75NSW 21/4/95 52

M

Prison Cooma Prison (CH) Natural
76NSW 23/5/95 54

M

Police Moama Bridge, Moama Injury
80NSW 26/7/95 18

M

Police Cobbs Road, Tuggerah Injury
81NSW 26/7/95 17

M

Police Cobbs Road, Tuggerah Injury
83NSW 26/9/95 44

M

Prison Long Bay Remand Centre Natural
87NSW 23/11/95 22

M

Prison Goulburn Prison Injury
91NSW 7/1/96 47

M

Prison Junee Prison Natural
92NSW 13/2/96 25

M

Prison Goulburn Prison Injury

Contents
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cover of report

A Report prepared by the

Office of the Aboriginal and Torres Strait Islander Social Justice Commissioner

for the

Aboriginal and Torres Strait Islander Commission

4NSW

Male 27, died on 25 July 1989
Long Bay Prison (Psych Unit), NSW
Self-inflicted, Hanging

Coronial Inquiry Derek Hand, Deputy NSW Coroner

Finding handed down 7 March 1990

Finding

The deceased hanged himself with the intention of taking his own life.

Summing Up

Circumstances of death

The deceased was in the psychiatric unit at Long Bay Prison. He approached a nurse on 25 July 1989 at 2.30pm and stated he was feeling ill. She gave him advice as to the illness and provided him with medication. He later approached another nurse and said he wanted to return to his cell. The nurse checked with a prison officer and he was taken to his cell at about 3.30pm. At 4.10pm he was discovered hanging in his cell.

Issues

The Coroner found the deceased was depressed and suffering paranoid schizophrenia, but concluded that he displayed no suicidal tendencies. The deceased had also denied being Aboriginal. The Coroner therefore held that the decision to allow the deceased to return to his cell was justified. However, the Coroner observed that stricter records should be kept by nursing staff and prison staff in regard to these matters.

The Coroner also expressed concern at the delay in personal notification of the deceased's death to the family. The family first heard of the death through the media.

Counsel for the family submitted that greater observation of prisoners was needed. The Coroner noted that supervision needs to conform with individual circumstances. He found the supervision to be appropriate in this case.

Recommendations Nil

Royal Commission Recommendations Breached

R19 Immediate personal and sensitive notification by custodial institution to deceased's family. (IR56)

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6NSW

Male 17, died on 21 October 1989
Maitland Gaol, NSW
Self-Inflicted Hanging

Coronial Inquiry Acting State Coroner Derek Hand

Finding handed down on 30 October 1990

Finding

The deceased hanged himself. The evidence did not enable the Coroner to say whether it was with the intention of taking his own life.

Summing Up

Circumstances of death

The deceased was detained at a juvenile institution, Endeavour House. He was transferred to an adult prison, at his own request, on the 18 October 1989. The prison was overcrowded. He was placed in a cell without a light switch or buzzer. He hanged himself and his body was discovered an estimated ten hours later.

Issues

The Aboriginal Legal Service argued that the deceased was depressed, angry and dispirited as a result of the regime at Endeavour House. There was no full-time psychologist, counsellor or youth welfare worker. Facilities were substandard. For example, there were no toilet facilities, only buckets and pans. The poor standard of care at Endeavour House led to four major riots in 1989. Procedures for granting consent to a transfer to an adult prison were arbitrary, and the Legal Service argued that the appalling conditions at the centre motivated the request. The deceased's request indicated that he was unable to perceive his own best interest and that he was under severe emotional strain. The Legal Service also submitted that the deceased's state of mind was affected by the suicide of a fellow detainee at Endeavour House and his incarceration at a maximum security gaol.

The Coroner, however, found that the deceased was not angry, dispirited and scared at the time of his transfer. The Coroner expressed concern at the standard of care at Endeavour House, but noted its closure. He criticised officers for allowing the deceased's application for transfer to the adult prison to be processed without counselling or consultation with the family. The Coroner was also critical of correctional authorities for using a cell with no light switch or buzzer and for placing the deceased in a cell by himself. The Coroner nonetheless refrained from making a general inquiry into Endeavour House or other institutions. The Coroner was not satisfied that the deceased intentionally hanged himself on the basis of a conversation the deceased reportedly had with an officer.

Recommendations

1. The Minister of Family and Community Services and the Corrective Services Commission implement Recommendations 228, 230 and 231 of the Kids Injustice Report of the New South Wales Law Foundation's Youth Justice Project:

228 Corrective Services should not accept transferees from institutions unless certain things have been carried out;

230 Every attempt should be made to accommodate juveniles together, and Aboriginal juveniles together, in prisons; and

231 Experienced youth workers should conduct programs for juveniles and other young prisoners in juvenile institutions and adult prisons

2. The transfer of a juvenile to a prison should only be considered after (i) the juvenile has received proper counselling and (ii) the family or next of kin have been sufficiently informed of such application and have been given the opportunity to appear or be represented at the hearing.

3. Any marked deterioration in a juvenile's physical or mental health or behaviour be notified to the family or the next of kin who should be invited to participate in supportive care and case planning.

Royal Commission Recommendations Breached

R150 Health care should be of equivalent standard as general community (IR38)

R151 Referral of Aboriginal prisoners/detainees for psychiatric care.

R152a Review of health services provided to Aboriginal detainees with AMS and other bodies to consider standard of health services available.

R152d Facilities for behaviourally disturbed.

R152g(iv) Protocols for care and management of Aboriginal prisoners at risk of self-harm.

R156 Assessment by medical practitioner within 72 hours of reception at prison

R157 Securing of comprehensive medical history from outside (IR36).

R167 Juvenile Detention Centres be reviewed to ensure compliance with custodial health and safety recommendations.

R173 Support for humane and shared custodial accommodation

Social Justice Commissioner

Comment

The clarity of these coronial findings is limited by an apparent lack of preparation. This is creates difficulties for both families and the institutions involved.

Additional Royal Commission Recommendations Breached

R 12 Legal requirement for Coroner to consider how the person was treated before death

Recommendations

Coroners to prepare clear summaries of circumstances of death and issues.

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7NSW

Male 28, died on 25 October 1989
Westmead Hospital, ex Silverwater Prison, NSW
Natural Causes, Encephalitis

Coronial Inquiry Senior Deputy State Coroner John Hiatt

Finding handed down on 28 February 1990

Finding

The deceased died from natural causes, acute cerebral oedema due to acute bacterial meningitis.

Summing Up
Circumstances of death

The deceased was sentenced to twelve months imprisonment for motor vehicle theft. He was an inmate at the Silverwater Prison Complex.

On Saturday 21 October 1989 at about 8pm the deceased complained of a headache and earache which had apparently started the day before. He was treated by nurses and was examined by Dr C on Monday 23 October. The doctor determined that he should be sent to Auburn District Hospital. Dr C had a provisional opinion of meningitis, but did not express it in his letter of reference which was received by Dr T. Dr T undertook testing of the deceased and formed an opinion that it was only a viral illness. The deceased was returned to prison. However, nurses at the prison sent the deceased back to the hospital on Tuesday 24 October. The deceased's condition deteriorated and he was transferred to Westmead Hospital at 9.15pm where he died the following day.

Issues

The Coroner found that prison custodial and medical staff had reacted in the appropriate manner. He noted that the deceased's mother had earlier informed a police officer of the deceased's complaint of an earache. However, the deceased had declined to have it treated until he approached officers on 21 October 1989. The Coroner found that once alerted, prison staff reacted quickly and competently.

The Coroner declined to make comment on the actions of the medical practitioners, stating that it was a matter for another tribunal. However, he noted the failure of Dr C to communicate his opinion to Dr T, the inability of staff at Auburn Hospital to locate the results of Dr T's tests and a delay in carrying out a lumbar puncture.

Recommendations Nil

Royal Commission Recommendations Breached

R130 Agreed rules for sharing information between police and corrective service on matters affecting risk.

Social Justice Commissioner

Comment

The Coroner did not refer the matter to the relevant tribunal or organisation, as the Coroner did in profile 37NSW. The background to the profile of the deceased also reveals case also discloses another example of the need for programs to address motor vehicle offending.

Additional Royal Commission Recommendations Breached

R95 Where motor vehicle offences are a major factor in imprisonment, programs to be consultatively developed to reduce incidence.

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10NSW

Male 24, died on 8 January 1990
Parklea Prison, NSW
Drug Overdose

Coronial Inquiry Senior Deputy State Coroner John Hiatt

Finding handed down on 18 May 1990

Finding

The deceased died from aspiration pneumonia following self-ingestion of illicit methadone.

Summing-Up
Circumstances of Death

The deceased was a prisoner at Parklea Prison and on 20 December 1989 made an application to share a cell with another prisoner. The application was granted. Prison Officers did not have access to the their medical files. The files revealed that both the deceased and the other prisoner were heroin addicts and the latter was also on the methadone program.

They were both observed to be under the influence of an illicit drug on 6 January 1990. The deceased again consumed the bulk of a 100mg contained of methadone the following night. The deceased was discovered in the cell at 8.30am 8 January and was taken to Blacktown District Hospital where he died.

Issues

The Coroner found that the two prisoners should not have been permitted to share a cell. They were both drug addicts and were observed on 6 January 1996 to be under the influence of drugs. The Coroner found that Prison Officers should have access to prisoner's medical histories to avoid such situations.

Recommendations

Minister for Corrective Services allow access by custodial officers to prisoner's medical files.

Royal Commission Recommendations Breached

R152f Guidelines for exchange of information between medical and prison services

R152g(ii) Protocols for care and management of Aboriginal prisoners who are intoxicated

R153b Confidentiality issues between prison staff and prisoners to be addressed

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19NSW

Male 19, died on 31 May 1990
Long Bay Gaol, NSW
Natural Causes, Epilepsy

Coronial Inquiry State Coroner Kevin Waller

Finding handed down on the 29 January 1991

Finding

Deceased died of natural cause, namely epilepsy

Summing-Up
Circumstances of Death

The transcript of the coronial proceedings was accidentally destroyed. Information regarding the death is limited to witness statements and a newspaper article. 1

The deceased was involved in a car crash at the age of sixteen. He suffered brain damage and the onset of fits. The family believe this precipitated the deceased's aggresive behaviour which led to his conviction in January 1990 for a range of minor offences, and his subsequent conviction for burglary in March in relation to offences before his imprisonment. He was due for release in March 1992.

He was initially depressed but improved after being moved into a cell with his brother. When the deceased suffered fits his brother was able to call for help. A month before his death the deceased's brother was transferred and the deceased was moved in with a stranger.

Two police seargants in their 'Report of Death to Coroner' state that the deceased refused to take his prescribed medication, 200mg Dilantin, at 8.20am 30 May 1990. However, the seargants provide inconsistent evidence as to the identity of the officer who attended the cell with the deceased's medication.

A Prison Officer checked the deceased's cell at 7.45am the following morning. After the deceased gave no response, he touched his body and called for assistance. Resuscitation equipment was later brought but the deceased could not be revived.

Recommendations

Unknown

Royal Commission Recommendations Breached

Unknown

Social Justice Commissioner

Comment

The case raises a number of issues. First, the placement of the deceased in a cell with a prisoner unable to care for him. Second, the refusal of the deceased to take his medication. While a person has a right to decline medication the psychiatrist's report to the Coroner indicates that the deceased was potentially suicidal and that his behaviour was unpredictable. Prison officers should have known of his suicidal ideations (Royal Commission recommendation 152f and 152giv) and taken appropriate efforts to ensure that medication was taken. Third, the prison officers were unable to perform resuscitation, and had to wait for medical staff to arrive.

The deceased's criminal history raises important issues. The deceased was first sentenced on 5 January 1990 to six months imprisonment for a number of charges: using offensive language; resisting arrest; assaulting a police officer; maliciously damaging property; maliciously destroying property; and simple larceny.

A recent study found that between 1990 and 1992 the only people imprisoned in New South Wales for maliciously damaging property were Aboriginal. 2 Six months imprisonment instead of an appropriate alternative for these offences seems difficult to justify in light of the deceased's age, psychiatric problems and absence of criminal record. The deceased's subsequent sentence of two years imprisonment for burglary also seems questionable.

Additional Royal Commission Recommendations Breached

IR1 Legislation to enforce principle of imprisonment as sanction of last resort

IR8 Arrest for minor offences to be avoided when alternatives are available

IR41 Automatic resuscitation equipment be available in police stations and prisons

R86 Offensive language during police initiated action not to be basis for arrest and charge, and monitoring to ensure compliance.

R87 Police to apply arrest as a final sanction, and implement practical procedures to ensure this occurs.

R92 Legislation to enforce principle of imprisonment as sanction of last resort.

R158 First priority on finding a person apparently dead to be resuscitation and medical assistance.

R159 Availability of safe, effective resuscitation equipment and trained staff in all prisons and watch houses.

R160 Basic training for all police and prison officers in resuscitation techniques.

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26NSW

Male 25, died on 28/9 May 1991 Lithgow Prison, NSW
Natural Causes, Diabetes

Coronial Inquiry State Coroner Gregory Glass

Finding handed down on 8 April 1992

Finding

The deceased died from the effects of hypoglycaemia due to unstable insulin - dependent diabetes mellitus.

Summing Up 3

Circumstances of death

The deceased was imprisoned the offence of robbery. He was diagnosed as having diabetes in 1970. He later contracted AIDS. His diabetic condition was very difficult to control and he frequently experienced symptoms of hypoglycaemia. The deceased was transferred to Lithgow Prison from Long Bay Prison on 22 May 1991 at his request.

On 27 May the deceased reportedly experienced a hypoglycaemic fit. He was locked in his cell at 8pm on Tuesday 28 May. The cell was opened the following morning at 7.50am and the deceased was found lying face down on his bed. Resuscitation was unsuccessfully attempted.

Issues

The Coroner found that a specialist should have checked the deceased at regular intervals. He also found that the deceased should have been in a cell with another prisoner. A prisoner who had previously shared a cell with the deceased at Long Bay gave evidence as to the assistance he gave the deceased when he suffered fits. However, Lithgow prison only had buddy cells - two cells joined by a door.

Recommendations

The Coroner commented on the need for 'specialist supervision in these sort of cases'.

Royal Commission Recommendations Breached

R152g(iii) Protocols for care and management of Aboriginal prisoners who suffer illnesses.

R173 Support for humane and shared custodial accommodation.

Social Justice Commissioner

Comment

A Prison Officer in evidence indicated the lack of information received by prison staff from medical staff due to confidentiality between medical staff and prisoners. Prison officers were unaware of the need for the deceased to share a cell because of his condition.

Additional Royal Commission Recommendations Breached

152f Guidelines for exchange of information between medical and prison services.

153b Confidentiality issues between prison staff and prisoners to be addressed.

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27NSW

Male 35, died on 10 June 1991
Parklea Prison, NSW
Self-mutilation

Coronial Inquiry Senior Deputy State Coroner John Hiatt

Finding handed down on 17 January 1992

Finding

The deceased died from incised wounds to the ante cubital fossae, self-inflicted then and there with intention of taking his own life.

Summing Up

Circumstances of death

In the weeks prior to the death of the deceased a psychiatrist assessed the deceased as a moderate suicide risk. He considered that the deceased should be transferred to Parramatta Prison. This was also the view of the Doctor who approved the deceased's discharge from Long Bay.

The psychiatrist communicated his concerns to the relieving superintendent at Long Bay Hospital. These concerns, however, were not passed onto the Superintendent responsible for Classifications and Placement. Instead the Long Bay Placement Committee acted on a 3 month old recommendation of the Cessnock Placement Committee and the deceased was transferred to Parklea Prison.

On reception the deceased was interviewed by a nurse. The nurse also received medical information on the deceased from Long Bay Prison. She advised a prison officer that the deceased should not be placed in a cell by himself (a one out cell). However, she did not inform the officer of the reasons 'because of a so called patient confidentiality principle'.

The prison officer, despite the advice, placed the deceased in a cell by himself. This accorded with the deceased's wishes and without further information, custodial factors were favoured over medical factors. The deceased was placed in a cell and left alone with a razor. The situation was not later rectified by the Parklea Reception Committee. The Committee did not have access to the prisoners medical file.

The deceased was discovered on 10 June 1991 in his cells having died from self-inflicted wounds through the use of a razor.

Issues

The Coroner found that recommendations from three earlier inquests concerning exchange of information had not been implemented, indicating the need to implement recommendation 15 which requires that departments report within three months on implementation of coronial recommendations. He found evidence of negligence by individuals in their care of the deceased but not sufficient evidence to justify criminal proceedings. The Coroner held that the unexpected transfer to Parklea instead of Parramatta, and the placement of the deceased in a cell one-out with a razor, contributed to the deceased's death.

The Coroner criticised: (i) the inadequate recording of information by the Superintendent; (ii) the failure of the various committees to consider the deceased's medical file; and (iii) the failure of medical officers and staff to disclose medical information for ethical reasons which were not justified in this case. He made recommendations to this effect.

Recommendations

1. That in respect of persons at risk or with serious behavioural problems or who are mentally disturbed, short of certified current psychiatric experience, a Crisis Intervention Unit be established for their accommodation and care until they are certified fit to return the routine of prison.

2. Prisoner medical files shall be forwarded with the prisoner when that prisoner s transferred from one gaol, institution or unit within the prison system to another

3. Where a medical officer assesses a prisoner as being mentally disturbed such information shall be passed on to Corrective Services in order that adequate care can be provided. That this procedure be made part of prison regulations and, if necessary, provide for release from liability medical officers or medical staff who disclose such information. 4

4. Proper and adequate records be kept of all telephone calls in respect of prisoners.

Royal Commission Recommendations Breached

R15 Responsibility of institutions to report on implementation of Coroner's recommendations within three months.

R122 Police and custodial authorities to recognise their legal duty of care to persons in their custody.

R 152d Facilities for behaviourally disturbed.

R 152f Guidelines for exchange of information between medical and prison services.

R 152giv Protocols for care and management of Aboriginal prisoners at risk of self-harm.

R 153b Confidentiality issues between prison staff and prisoners to be addressed.

R 157 Securing of comprehensive medical history from outside. To accompany prisoner on transfers.

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28NSW

Male 25, died on 12 June 1991
Prison Henry Hospital (Long Bay Prison), NSW
Natural Causes, Heart Attack

Coronial Inquiry Deputy State Coroner Gregory Glass,

Finding handed down on 13 February 1992

Finding

The deceased died from the effects of a cardiac arrest following laparoty for carcinoma of the bowel associated with ischaemic heart disease, atherosclerosis and iron deficiency anaemia.

Summing Up

Circumstances of death

The deceased was imprisoned for sex offences. He was an inmate at Long Bay Gaol. He was admitted to the Prison Annex, Prince Henry Hospital, on 4/6/91 after complaining of abdominal pain. He underwent transfusion and ECG. He underwent operative surgery for cancerous bowel section on the afternoon of 12 June 1991. At 7.10pm he was returned the Prison Annex for recovery. The deceased then suffered a heart attack at 7.52pm. Hospital staff attempted resuscitation but without success.

Issues

The inquest was brief as the family was not present or legally represented. The NSW Aboriginal Legal Service received the brief of evidence but indicated they would not be appearing. The Coroner found that sufficient efforts were made to ensure representation for the family.

The Coroner considered the need for an emergency buzzer for the nurse in the Prison Annex at Prince Henry Hospital. However, he found that the absence of the buzzer did not contribute to the death of the deceased: a telephone call was promptly made and the doors to the Annex were immediately opened for support staff.

Recommendations

In the transcript, the Coroner put forward the suggestion of installing an emergency buzzer in the Hospital Annex where prisoners are treated (p.6).

Royal Commission Recommendations Breached

R253 Design and operation of health facilities to consider needs of Aboriginal people particularly where their population is concentrated.

Social Justice Commissioner

Comment

The Coroner could have questioned hospital staff about their awareness of the deceased's Aboriginality and heart condition and the need for preventative action.

Additional Royal Commission Recommendations Breached

R12 Legal requirement for Coroner to consider how the person was treated before death

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37NSW

Male 23, died on 5 March 1992
Prince Henry Hospital (ex Long Bay Gaol), NSW
Heart Attack

Coronial Inquiry State Coroner Derek Hand

Finding handed down on the 1 September 1993

Finding

At the Prince Henry Hospital, Malabar, and whilst temporarily absent from the Long Bay Prison Hospital, the deceased died of effects of a natural cause namely ischaemic heart disease due to atherosclerosis. Papers were to be referred to the Nurses Registration Board in regard to the actions of a certain nurse.

Summing Up

Circumstances of death

The deceased was sentenced at Walgett Local Court on 18 February 1992 to four months imprisonment for concealing a serious crime. He had attended Walgett Hospital four days earlier complaining of a 'pain in the gut' and had been treated for angina.

Upon reception at Bathurst Gaol on 20 February 1992 he complained he had been feeling unwell for the past three weeks. On 24 February he was seen by a doctor. A chest x-ray on 28 February revealed slight cardiac enlargement.

He was transferred to Long Bay Prison Hospital by car rather than ambulance on 2 March 1992. He was taken to Prince Henry Hospital two days later as his condition worsened.

On 5 March 1992 a nurse administered the deceased the wrong medication. He died the same day as a result of a heart failure.

Issues

Family for the deceased submitted that staff at Walgett Hospital inadequately cared for the deceased in several respects. They failed to obtain an adequate medical history, or determine the symptoms and underlying cause. They demonstrated a lack of knowledge sufficient to screen Aboriginal patients. Counsel submitted that had the deceased's condition been detected it may have been arrested and the deceased's would not have been required to attend Walgett court on 18 February.

The Coroner found, however, that care at Walgett Hospital was adequate. He found that their poor prognosis was justified given the deceased's description of his problem as a 'pain in the gut'. He also commented that the deceased failed to attend the Aboriginal Medical Service as advised.

The family submitted that the Prison Medical Service at Bathurst failed to provide adequate medical attention to the deceased between 19 February 1992 and 2 March 1992. The Coroner found, however, that the deceased indicated little to staff and failed to turn up to a medical parade. He found that doctors took immediate action once they received the x-ray results.

The Coroner, however, agreed with the family for the deceased that it was inappropriate for Bathurst Prison to transport the deceased by car and not ambulance on the three hour trip to Long Bay Prison Hospital.

The Coroner found that the actions of the nurse in administering the wrong medication did not amount to a criminal offence or gross negligence. Counsel for the nurse had conceded that such actions can amount to negligence. The Coroner referred the matter to the Medical Complaints Tribunal. The Coroner also noted that the delay in the arrival of the doctor after the incident but found that it made no contribution to the deceased's's death.

Recommendations

The Coroner was satisfied that the appropriate changes had been made regarding transfer of patients from Bathurst and protocols for administration of medication.

Royal Commission Recommendations Breached

R152giii Protocols for care and management of Aboriginal prisoners who suffer illnesses.

Social Justice Commissioner

Comment

Counsel for the family has stated that: 'to say that the Coroner's findings were "skinny" and not a fair reflection of the state of evidence is probably a gross understatement'.

The charge of concealing a serious crime is an unusual one. It was heard in a local court and attracted a relatively minor prison term, casting doubts on the seriousness of the underlying facts. The Coroner did not address the propriety of the original conviction, probably because the police investigation failed to do so.

Issues of medical care also arise. The Coroner's findings place undue emphasis on the responsibility of the deceased to report symptoms. The staff at Walgett Hospital could have taken extra precaution. The Royal Commission found the: 'communication difficulties often resulted in Aboriginal people being misdiagnosed'. 5 It recommended that medical staff in hospitals be sensitive to Aboriginal people (R247), their propensity to have certain illnesses (R252, R253) and styles of operation to be considered when advice is not complied with by Aboriginal patient (R263).

These deficiencies were repeated at Bathurst Prison due to the non-implementation of recommendations relating to Prison Medical Services. The deceased was not seen by a doctor within 72 hours of arrival (R156) and a comprehensive medical history was not obtained (R152e, R157). The deceased's medical history and his Aboriginality should have indicated a risk of heart disease (R155, R154a).

Additional Royal Commission Recommendations Breached

R35 Police investigations should: be approached on the basis that the death may be a homicide; inquire into the arrest or apprehension, lawfulness of custody and treatment and supervision of the deceased; and thoroughly examine the scene of death and forensic exhibits.

R152e Information exchange between prison and other medical services

R154a Prison medical services staff to be trained in Aboriginal history, culture and lifestyle.

R156 Assessment by medical practitioner within 72 hours of reception at prison

R157 Securing of comprehensive medical history from outside. To accompany prisoner on transfers.

R247 More/improved training of non-Aboriginal health professionals in Aboriginal culture and society and life threatening conditions which are experienced by Aboriginal people.

R252 Review of casualty procedures in hospitals regularly attended by Aboriginal people to minimise risk of incorrect diagnosis and treatment.

R253 Design and operation of health facilities to consider needs of Aboriginal people particularly where their population is concentrated.

R263 Health professionals to examine styles of operation when high level of non-compliance with advice by Aboriginal patients.

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39NSW

Female 38, died on 10 June 1992
Macquarie Fields Police Station, NSW
Self-Inflicted Hanging

Coronial Inquiry Senior Deputy State Coroner John Hiatt

Finding handed down on 24 December 1993

Finding

The deceased hanged herself with the Intention of taking her own life.

Summing Up

Circumstances of death

The deceased was convicted at Fairfield Local Court on 29 April 1992 on a number of drug charges and sentenced to one month imprisonment. The deceased appealed to the District Court. Conviction and sentence were stayed on her entering bail subject to conditions, which included supervision of the Community Correction Service and drug testing.

On 9 June 1992, when the appeal was to be heard, the deceased decided to withdraw her appeal and serve the one month sentence. She was taken to Macquarie Fields Police Station and detained there overnight while she awaited transfer to Mulawa Prison. She was found at 6am the following morning hanging by her panty hose.

Issues

The Coroner was critical of procedures adopted by Police and the Department of Corrective Services. Freshly sentenced prisoners were detained in police cells instead of being immediately transferred to prison where they would receive better care. This practice was in breach of the court warrant, the Prisons Act and the Police Commissioner's instructions. It was apparently condoned by Government Ministers for a number of years.

The Coroner also found custodial care at Macquarie Fields Police Station to be substandard. The assessment form was filled out incorrectly and the officer failed to inquire of the deceased whether she was Aboriginal. Indeed, the Coroner was critical that neither the police, nor the courts nor Corrective Services had ascertained her Aboriginality. Furthermore, the police officers looking after prisoners at Macquarie Fields were inexperienced and failed to regularly observe the deceased.

The Coroner found that the evidence did not establish a criminal offence on the part of any officer but that there was prima facie evidence of negligence.

Finally, the Coroner noted that police need to use 'every legitimate means to divert offenders from custody, using custody as a last resort'.

Recommendations

The Coroner made extensive recommendations which can be summarised as follows:

1. Timely preparation of warrants and orders for imprisonment.

2. Court documents should identify Aboriginality and risk status and contain other relevant medical information.

3. Speedy classification of sentenced prisoners and their removal from the court complex on the same day.

4. Prisoners detained in police cells must be kept in nominated police stations which have safe cells with trained staff, monitors and computer operated alarm buttons.

5. Auxiliary staff (registered nurse or similarly qualified) to assist police in the medical assessment of prisoners at these nominated police stations.

6. Police use every legitimate means to divert offenders from custody.

Royal Commission Recommendations Breached

R87 Arrest to be the sanction of last resort
R92 Imprisonment be utilized as a sanction of last resort
R122 Police and custodial authorities to recognise their legal duty of care to persons in their custody
R123 Instructions on care of persons in custody to be known, understood, enforceable and publicly available.
R126 Before person placed in cell screening form to be completed carefully
R127a Regular medical or nursing presence in watch-houses
R127e Liaison between Aboriginal Health Services for transfer of information
R127fiii Developments of protocols for management of persons likely to self-harm
R128 Persons detained by police on behalf of Corrective Services to have equivalent standard of health care
R133 Police officers receive training to identify persons at risk of death or injury
R137 Regular, careful and thorough observation of detainees in police cells
R138 Adequate police recording of observations/information relating to detainees health
R144 Aboriginal detainees should not be placed alone in a cell
R148 Safe and humane cells

Social Justice Commissioner

Comment

The Coroner only made a brief comment on the need for diversion from custody and imprisonment as a last resort. The chairman of the Aboriginal Legal Service, however, commented that the deceased was jailed for a 'very, very minor' cannabis offence. Other alternatives were available such as a fine or weekend detention. He also stated that the magistrate at Campbelltown Local Court refused to allow the preparation of a pre-sentence report which would have revealed that the deceased's medical history. The deceased was also the mother of three children.

The Coroner has jurisdiction under s22A(1) to make recommendations as the coroner 'considers necessary or desirable to make in relation to any matter connected with the death'. S22A(2) gives 'public health and safety' as examples that can be the subject of a recommendation. Nevertheless, administration of justice falls under the wide umbrella of s22A(1). The Coroners Act in Victoria s19(2) explicitly states that a coroner may comment on a matter connected with administration of justice.

Additional Royal Commission Recommendations Breached

R12 Legal requirement for Coroner to consider how the person was treated before death

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40NSW

Male 14, died on 3 July 1992
Police, Batemans Bay, NSW
Injuries in Car Accident, Police Pursuit

Coronial Inquiry State Coroner Gregory Glass

Finding handed down on the 6 August 1993

Finding

The Coroner found that there was a prima facie case against a known person for an indictable offence which may have caused the death. The Coroner therefore terminated the inquest under section 19 of the Coroner's Act 1980 after taking evidence to establish death, identity of deceased and date and place of death.

However, the Coroner provided comments on, and recommendations with respect to, other possible causes of the death and surrounding circumstances.

Summing Up

Circumstances of Death

The deceased and another minor stole a motor vehicle from Narooma. Police at the Moruya Bridge recorded the vehicle travelling at 111kph in a 60kph zone. A police pursuit commenced with sirens and warning lights. The stolen vehicle accelerated to speeds of 140-160kph.

The vehicle subsequently turned north onto the Princes Highway. Four kilometres south of Batemans Bay the stolen vehicle veered to the incorrect side of the road, failed to negotiate a sweeping left curve and ran up the slight embankment on the eastern side of the road. The vehicle nose dived down a depression, rolled over, ejecting the two occupants who had earlier removed their seatbelts. The deceased subsequently died in the ambulance en route to Batemans Bay hospital.

Issues

The Coroner in the course of his findings considered the appropriateness and execution of the police pursuit and the police investigation into the death.

The family submitted that police pursuits are not justified in any circumstances. The Coroner agreed that high-speed police pursuits are dangerous and potentially hazardous. However, he held that high-speed pursuits are justified when it is necessary for the protection of society.

The Coroner found that the Safe Driving Policy, released six months after the deceased's death, was consistent with this view. The policy established public safety as the utmost consideration in the determination of whether or not to embark upon high speed pursuit. A senior officer was to take overriding control of the pursuit situation. The policy requires that prevailing conditions, legal and welfare aspects and department guidelines be constantly considered. High-speed pursuit was to be an option of last resort. Further, a graded police driver licence system and new training programs were introduced.

The Coroner then considered the pursuit in this case, and found it was lawful and justified in the circumstances since:

(i) the police officers were suitably qualified;
(ii) regular communication occurred between police and the senior operations officer;
(iii) traffic, road and weather conditions were good;
(iv) the stolen vehicle was travelling at high speed when it first came under notice;
(v) the driver of stolen vehicle was driving competently (police did not realise they were juveniles) and had slowed down to 60-80 kph through a small town;
(vi) the vehicle was stolen;
(vii) other motorists were alerted by sirens, flashing lights and a police vehicle ahead of the pursuit; and
(vii) the police intended to call off the chase before they reached Batemans Bay.

The Coroner considered that the chase was justified on the grounds that the vehicle was stolen, because the offenders would not be otherwise located and because car theft was a serious offence. However, the Coroner did note that communication was sometimes poor between police and the highway was hilly with sweeping right and left curves.

The Coroner concluded that the police pursuit contributed to the death of the deceased but rejected the family's submission that police could be held responsible.

The Coroner considered the police investigation after the death. He found, in accordance with the Royal Commission report 6, that the police involved should have been interviewed and not merely requested to make statements. He noted that police were reluctant to adopt such a procedure as they feared they would be treated like criminals. Nevertheless the Coroner found independent investigation (see Royal Commission recommendation 33) was essential for the credibility of the investigation.

The Coroner further found that police had not complied with Royal Commission recommendation 35. The steering wheel was not fingerprinted, clothing of the deceased was destroyed and the motor vehicle was lost. The Coroner also commented that a system for the appointment of Counsel Assisting the Coroner within 48 hours after the death be instituted.

Recommendations

The Coroner provided various unofficial recommendations in the course of his findings:

1. Records of interview, as opposed to statements, must be taken from officers involved in the circumstances of a death.

2. No article of possible forensic significance should be disposed of or left unsecured until the coronial inquest has concluded and then only with the permission of the Coroner.

3. Appointment of Counsel Assisting the Coroner within forty-eight hours of death.

Royal Commission Recommendations Breached

R26 Lawyer to assist Coroner to be appointed within forty-eight hours of advice of a death in custody.

R33 Independence of officers investigating a death in custody.

R35 Police investigations should: be approached on the basis that the death may be a homicide; inquire into the arrest or apprehension, lawfulness of custody and treatment and supervision of the deceased; and thoroughly examine the scene of death and forensic exhibits.

R36 Investigation to provide thorough evidentiary base for coronial inquest.

Social Justice Commissioner

Comment

The Coroner gave qualified support for car chases as a last resort. However, experiences in other States, notably Western Australia, indicate the dangers of such a policy in practical terms. Police pursuits are dangerous. In the present case the 'sweeping curves' of the road received little attention from Coroner. Perhaps police should look to alternatives to pursuit, such as helicopters or roadblocks.

The risks and danger of high speed car pursuits involving young people is well documented. High speed car chases should be banned where children or young people are drivers or passengers of the vehicle.

Additional Royal Commission Recommendations Breached

R60 Elimination of, and disciplining for, rough police treatment of Aboriginal persons.

R95 If motor vehicle offences are a major factor in Aboriginal imprisonment, programs should be developed to reduce the incidence of such offences.

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42NSW

Male 43, died on 24 November 1992
Moorebank, Police Custody, NSW
Drug Overdose

Coronial Inquiry Senior Deputy State Coroner John Hiatt

Finding handed down on 31 March 1994

Finding

The deceased died in the back of Police Truck Windsor 3 at Glossodia from acute dothiepin poisoning as a result of self-ingestion of prothiaden.

Summing Up

Circumstances of death

The deceased was prescribed an anti-depressant containing prothiaden. The deceased, against medical advice, ingested more than one tablet and concurrently consumed other drugs. He consequently experienced hallucinations from the afternoon of 23 November 1992.

The deceased entered a neighbouring property on Shepherds Rd at 11am on the following morning. He told the woman on the property that men were outside with guns. The woman rang her husband, who rang the police. The husband arrived and took the family from the property. The police also arrived. The deceased ran towards them gesticulating towards the rear of the property. He then ran off towards the rear of the property. The Police pursued the deceased. He was restrained after a struggle with police, handcuffed, and placed in the back of the Police truck.

Police officers then searched without success for armed persons on the property. The Police Officer guarding then heard the deceased make certain sounds. He entered the back of the truck and found the deceased had no pulse. The Police removed the deceased from the truck and an ambulance was called. No resuscitation was attempted as no equipment could be located.

Issues

The family raised concerns as to the initial treatment of the deceased. They put it to the Coroner that the handcuffing was unjustified, that the deceased was thrown into the van, roughly handled and possibly trodden on by police officers, and that no police officer remained to watch the deceased. The Coroner found that restraint of the deceased was reasonable in the circumstances due to the report of armed persons on the property. The Coroner held that evidence from the owner of the property was sufficient for a finding that the deceased was properly placed in the van. He also found that a police officer remained to watch the deceased as this was the means by which the police detected the deceased's condition.

The family further submitted that police treatment was substandard on discovery of the deceased's condition. The sister in law of the deceased, who had arrived at the scene minutes after the arrest, testified that the deceased was dragged from the van and that his head hit the rear of the police truck or the ground. The Coroner found that there were inconsistencies in the evidence from the relatives, and that their evidence was a fabrication. He found that a police officer entered the van, took the deceased's pulse and with another constable lifted the deceased from the van and placed him on the ground.

The Coroner also held that police were justified in not carrying out resuscitation without equipment. He accepted evidence that green discharge had emanated from the deceased's nose and mouth and that the detective knew of the deceased's drug history. However, the Coroner found that police should have had resuscitation equipment in their vehicle.

Recommendations

A reminder was forwarded by the court to the Commissioner of Police to make certain that all patrol commanders be required to ensure that such equipment is regularly checked, serviced and available in those vehicles.

Royal Commission Recommendations Breached

R159 All prisons and watch-houses should have resuscitation equipment. 7

Social Justice Commissioner

Comment

This case demonstrates the dangers of placing people unattended in police vans. There have been four Aboriginal deaths in police vans since May 1989, and in these cases only one woman arrested for intoxication was not handcuffed in the back of the van. Recommendation 133 specifies that police receive training to identify persons in distress or at risk of death and the dangers associated with detaining unconscious or semi-rousable persons. In this case, police out of view of the deceased were unable to take appropriate action at the earliest possible moment.

Additional Royal Commission Recommendations Breached

R 133 Training of police officers to recognise those in distress or a risk.

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44NSW

Male 64, died on 10th March 1993
Prince Henry Hospital (ex Cooma Prison), NSW
Natural Causes, Cancer

Coronial Inquiry State Coroner Gregory Glass

Finding handed down on 16 September 1993

Finding

The deceased died from the effects of a differentiated carcinoma of the lung with hepatic metastases.

Summing Up 8

Circumstances of death

The deceased was sentenced to 12 years imprisonment on the 3 November 1989 for sex offences. The Australian Capital Territory judge recommended that: 'prison authorities give early and particular attention to the deceased's classification and security and to the treatment of his asbestosis.' However, there was no evidence to suggest that the deceased was seen by a doctor before March 1990. On 13 March 1990 x-rays were taken with further x-rays being taken on 31 May 1990, 9 February 1992 and 7 February 1993.

The deceased's condition rapidly deteriorated in February 1993 and he was taken to Prince Henry Hospital on 28 February 1993. He subsequently died on 10 March 1993 from lung cancer.

Issues

The Coroner found that the deceased should have been immediately seen by a doctor when his condition began to deteriorate and that an x-ray should have been conducted in 1991. He also criticised the medical services for inadequate medical notes. However, the Coroner held that these omissions did not contribute to the death of the deceased since the deceased's health only deteriorated in the few weeks before his death.

The Coroner also expressed concern at certain communications that passed from Corrective Services staff to the family of the deceased. Counsel for Corrective Services was instructed to ensure that the letters passed onto the Assistant Commissioner Operations for appropriate action regarding comments made by his staff.

Recommendations Nil.

Royal Commission Recommendations Breached

R152g(iii) Protocols for care and management of prisoners who suffer illnesses.

R156 Assessment by medical practitioner within 72 hours of reception at prison.

R157 Securing of comprehensive medical history from outside. To accompany prisoner on transfers.

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46NSW

Male 20, died on 26 May 1993
John Moroney Correction Centre, NSW
Epilepsy

Coronial Inquiry Senior Deputy State Coroner John Hiatt

Finding handed down on 4 August 1994

Finding

The deceased died of natural causes, epilepsy.

Summing Up

Circumstances of death

The deceased had been on remand at John Moroney Correctional Centre since 30 June 1992. He was sentenced to a minimum of five years and four months for robbery offences on 12 February 1993.

The deceased was observed on 21 May 1993 to be under the influence of drugs. The deceased reported that he had taken a double dose of Rivotril, which was prescribed for his epilepsy. The deceased was counselled against storing drugs and administering them in larger doses. From 21 May 1993 the deceased took his medication in the presence of a nurse. The deceased was subsequently found to be under the influence of unknown drugs on 23 May.

At 6.45pm 26 May Rivotril tablets were brought to the deceased's cell. The deceased was on the toilet at the time and the tablets were left in his cell. The deceased did not take the tablets.

The deceased was found by patrol officers at 5am 27 May. He was lying face down on his bed. The post-mortem report revealed the presence of doxepin and not rivotril. The deceased had died from an epileptic fit which was contributed by the non-prescribed drug doxepin.

Issues

The Coroner found that health care was equivalent to community standards in accordance with recommendation 150. He further found that a system existed in accordance with recommendation 152g for the identification of illness and intoxication with practised procedures of observations and supervision. The Coroner found, however, that further action was warranted by medical staff in light of the deceased's recent prior history of epileptic fits, illegal drug use and his failure to take medication. He held that the illegal drug should have been identified by the Prison Medical Service and greater vigilance exercised in ensuring the deceased took his medication. The Coroner also expressed concern at evidence regarding the storage and trading of drugs.

In response to submissions by the family the Coroner found that the Governor was justified in placing the deceased in a cell by himself. The deceased had faced threats from other prisoners. He also found that the conditions of the cell complied with recommendation 181.

The Coroner found that the post-death investigation was thorough and in accordance with recommendation 35 and 24 of the Royal Commission. However, he expressed concern at the delay in the attendance of the family and made a recommendation to this effect.

Recommendations

Recommendations were made to the Minister of Health that:

1. Where persons are known epileptics medical staff should regularly monitor them to ensure their anti-epileptic drug levels are within the therapeutic range. In any case, where such a prisoner is found to be intoxicated by a drug or otherwise, such monitoring should be compulsory; and

2. Practices and procedures adopted by Prison Medical Service for prescription and supply of drugs should be reviewed to ensure that prisoners cannot store and trade drugs. Prisoners be advised of the importance of taking their medication as prescribed and an acknowledgment of receipt of such advice be appropriately recorded.

Recommendations was made to the Aboriginal Justice Advisory Committee that:

3. Expeditious attendance at the scene of death is necessary so that proper pathological investigation can subsequently occur.

Recommendation was also made to the Commissioner of Police that:

4. He remind patrol commanders that notification of relatives in respect of deaths in custody be made at the earliest practical time after they are notified to ensure their expeditious arrival.

Royal Commission Recommendations Breached

R19 Immediate personal and sensitive notification by custodial institution

R152g(ii) Protocols for care and management of Aboriginal prisoners who are intoxicated.

R152g(iii) Protocols for care and management of Aboriginal prisoners who suffer illnesses.

Social Justice Commissioner

Comment

Family members remain convinced that, in light of his health, the issue of the placement of the deceased alone in a cell was not properly addressed by the Coroner.

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51NSW

Male 33, died on 29 October 1993
Long Bay Prison, NSW
Natural Causes, Heart Attack

 

Coronial Inquiry State Coroner Derek Hand

Finding handed down on 28 March 1995

Finding

The deceased, in cell 43 9 Wing Reception Industrial Centre Long Bay died of the effects of a natural cause, namely atherosclerotic cardio-vascular disease.

Summing Up

Circumstances of death

The deceased was sentenced to life imprisonment for murder. He appeared to be in good health and two doctors who had seen him prior to his death gave evidence to this effect. The deceased was in the vicinity of the toilet in his cell when he had a heart attack on the night between the 28 and 29 October 1993.

Issues

Counsel for the family submitted that Royal Commission recommendations were contravened since:

(i) the deceased's segregation affected his physical health;
(ii) the deceased was not properly screened;
(iii) his diet was unsatisfactory; and
(iv) the alarm may not have been working.

The Coroner found that the deceased had himself requested segregation. Counsel for the family cited the appalling conditions from a visit to Goulburn prison in 1989. The Coroner, however, rejected an application for an adjournment to call evidence on cell conditions.

The Coroner, on the evidence of the two doctors, found that the heart disease was not detectable. He accepted evidence from the manager of the prison catering service that the food was not greasy and was sufficiently healthy. He held the question of the alarm was not relevant since the deceased had the heart attack in his toilet.

Recommendations Nil.

Royal Commission Recommendations Breached Nil.

Social Justice Commissioner

Comment

There was a high degree of tension between the Coroner and Counsel for the family, possibly due to the application for a late adjournment to call more evidence and the raising of issues not relevant to coronial inquests.

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52NSW

Male 46, died on the 2 November 1993
Long Bay Prison, NSW
Heart Attack

Coronial Inquiry State Coroner Gregory Glass

Finding handed down on the 17 October 1994

Coroner's Formal Finding

The deceased died of a natural cause namely ischaemic heart disease following diabetes mellitus.

Summing-Up

Circumstances of death

The deceased was imprisoned for eight months at Long Bay for a break and enter offence. He had diabetes and a heart condition. A specialist physician found the deceased to be well on 13 July 1993. The deceased during the next six weeks failed to have regular checks on his blood sugar level and blood pressure. He also declined a review by an ophthalmologist.

The deceased complained of chest pain radiating down both arms on 24 August 1993. The doctor recommended he enter the prison hospital for treatment. The following day the deceased made a written statement to the prison authorities which stated: 'I do not want to have any medical treatment on 26 August 1993. I take all responsibility.' On 11 November 1993 he died from a heart attack.

Issues

Counsel for the family submitted that decline in the deceased's health could have been detected over the two month period. An inmate had testified that the deceased had deteriorated in appearance, was lethargic and off colour. The Coroner found that any deterioration would have been noticed by the nurses, clinic personnel or prison officers and action would have been taken. He also found that the deceased was familiar with his diabetes, knew the method for gaining access to a medical practitioner, was seen by a medical practitioner a week before his death and had declined to enter hospital for tests and observation.

Counsel for the family further submitted that involvement of the Aboriginal Medical Services (AMS), as recommended by the Royal Commission, would have induced the deceased to undergo medical tests. The Coroner found that the doctor had sufficient experience with Aboriginal patients and that AMS involvement would not have affected the decision made by the deceased.

Recommendations Nil

Royal Commission Recommendations Breached Nil

Social Justice Commissioner

Comment

The Coroner's response to the family's submissions are difficult to asses since they are assertions: medical and nursing staff would have noticed the change in the deceased's appearance and the AMS would not have produced a different result. It should also be noted that not all doctors who have had experience with Aboriginal patients have sensitivity to Aboriginal cultural and health problems.

There is also the question of the appropriateness of the deceased's imprisonment. He was sentenced to eight months imprisonment for stealing a few electrical tools.

The deceased is also known to have been removed as a child by welfare authorities.

Additional Royal Commission Recommendations Breached

R92 Legislation, where not in place, to enforce principle of imprisonment as sanction of last resort

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62NSW Female 30, died on 3 June 1994
Mulawa Prison, NSW
Natural Causes, Heart Complications

Coronial Inquiry State Coroner Derek Hand

Finding handed down on 18 August 1995

Finding

The deceased died from the effects of complications of mitral valve prosthesis endocarditis.

Summing Up

Circumstances of death

The deceased was placed in remand at Mulawa on a stealing charge on 27 May 1994. Reception forms completed at the Central Court and at Mulawa indicated that she had a heart condition and a scar from previous heart surgery. High blood pressure was also noted on the form, but her full medical history (aneurysm, spleen problem) was not recorded.

The officer gave the reception nurse a lodgment application form and brought to her attention that endocytis (sic) was highlighted on the form. The reception nurse, however, could not remember this and denied seeing any reference to endocarditis. These documents were passed on to the assessment nurse. This nurse, however, denied receiving the relevant documents until 30 May 1994. However, on that date the deceased went to court, and her documents went with her, casting doubt upon the nurse's evidence.

On May 31 1994 the reception nurse notified a doctor and informed her of the deceased's endocarditis. The had deceased had attended the doctor for endocarditis in 1992 when she was incarcerated in Norma Parker Correctional Centre, after the deceased's guardian had contacted the legal section at St Vincents Hospital in Sydney and they had advised her to carry out the necessary procedures to ensure the deceased received her medication in prison and that her medical records were available within Corrective Services. However, the doctor gave evidence that she did not remember the patient. She did not consult her files. The doctor formed the opinion that the deceased was merely undergoing drug withdrawal. It is doubtful whether drug withdrawal was ever a factor. She ordered certain tests but did not test the patient herself.

Between 31 May and 2 June 1994 prisoners told prison officers that the deceased was suffering more than drug withdrawal. The deceased was pale, not eating, and she had a fit and fallen. This was brought to the nurses attention. The deceased was taken to the medical annexe after suffering the fit on June 1, but there is evidence that there was a delay of at least three hours between the time she arrived at the annexe and the time she received medical attention. Nursing staff took merely took her pulse.

Prisoners also reported that on the nights of 1 and 2 June the deceased was moaning and groaning. Nurses denied hearing noises from the deceased. However, the prisoners' evidence was corroborated by a prison officer who was in the adjacent cell, attending to a prisoner who had stolen methadone and overdosed.

Issues

The Coroner was highly critical of the nursing and medical staff. He found that both the reception and assessment nurse had been sufficiently alerted to the deceased's condition and action should have been commenced earlier. He was critical of the doctor for not examining earlier files which would have resulted in her immediately examining the deceased. He was also critical of nurses for not taking action after comments by prisoners and hearing the deceased's moaning.

The deceased was detained alone in her cell despite the indications on the screening forms that she was a high medical risk.

The Coroner did not make any recommendations as the State Director for Nursing Services for Corrections Health Service submitted evidence of changes made since the death. These included:

i. part-time Medical Director at Mulawa;

ii. placement of prisoners in the annexe requires consent by medical practitioner;

iii. on call doctor and psychiatrist 24 hours a day;

iv. increase from one to three psychiatric nurses;

v. 120 female prisoners to be transferred to Emu Plains;

vi. codification of policies and procedures;

vii. medical alert form;

viii. health notification form for prison wing officers;

ix. clear definition of responsibilities of nurses at Mulawa;

x. co-ordination between Department of Corrective Services and Corrective Health Services;

xi. development of new safe cells; and

xii. increase in appointment of outside medical practitioners.

Recommendations Nil.

Royal Commission Recommendations Breached

R122 Police and custodial authorities to recognise their legal duty of care to persons in their custody.

R123 Instructions on care of persons in custody to be known, understood, enforceable and publicly available.

R124 Debriefing procedures to follow incidents (deaths/medical emergencies) to reduce future risks.

R136 People found unconscious or not easily roused to have immediate medical care.

R150 Health care should be of equivalent standard as general community.

R152a Review of health services provided to Aboriginal detainees with AMS and other bodies to consider standard of health services available.

R152f Guidelines for exchange of information between medical and prison services

R152gii Protocols for care and management of Aboriginal prisoners who suffer illnesses.

R154a Prison medical services staff to be trained in Aboriginal history, culture and lifestyle.

R157 Securing of comprehensive medical history from outside and from previous instances of incarceration. To accompany prisoner on transfers.

R161 Instructions to seek immediate medical care if doubts arise about a prisoner's condition.

R179 Simplification of procedures for prisoner requests/other matters.

R182 Instruction of Corrective service officers for courteous interaction with prisoners; any deliberate breach to be a disciplinary matter.

Social Justice Commissioner

Comment

There is some uncertainty as to whether the problems which made the circumstances of this death so appalling have been properly remedied. Where an prison medical employee takes the view that a condition is not serious, there is no alternative source of medical assistance a distressed inmate can turn to. This heightens the need for good quality medical services in correctional facilities. An adequately accessible complaints mechanism following the model of recommendation 176 would also have assisted in this case.

The case amply demonstrates the necessity of NSW Correction Health Services properly implementing recommendation 156, which requires that a medical practitioner assess a prisoner within 72 hours of reception. The Coroner established that a simple heart check generally detects the murmurs which indicate endocarditis. Proper implementation of this recommendation 156 would allow the Corrections Health Service to detect health problems much earlier.

The deceased was detained by police at the Central Court on behalf of Corrective Services in two occasions, once on May 27 and once on June 30 for sentencing. Medical assistance was not sought.

Finally, the family has been undergoing counselling (the deceased left a son in the guardianship of her next of kin) but there has been no offer of funding from Corrective Services according to recommendation 5. There has been no attempt to negotiate a settlement with the family under recommendation 4.

Additional Royal Commission Recommendations Breached

R4b Governments should, wherever appropriate, make the effort to settle claims by negotiation so as to avoid further distress to families by litigation.

R5 Funding for counselling, in recognition of grief and trauma experienced by the families of those who have died in custody.

R128 Persons detained by police on behalf of Corrective Services to have equivalent standard of health care.

R156 Assessment by medical practitioner within 72 hours of reception at prison.

R176 Establishment (and functions) of an independent Complaints officer for each prison, to be responsible to the Ombudsman or Minister for Justice.

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63NSW

Male 24, died on the 19 June 1994
Long Bay Prison, NSW
Self-Inflicted Hanging

Coronial Inquiry Deputy State Coroner John Abernathy

Finding handed down on 29 May 1995

Finding

The deceased died in the Remand Centre, Long Bay Correctional Centre, when he hanged himself with the intention of taking his own life.

Summing Up

Circumstances of death

The deceased was on remand awaiting trial for an assault offence. He indicated to police his intention to commit suicide. This information was in turn conveyed to the Department of Corrective Services. The deceased was placed in a cell two-out with his cousin.

After lunch on 19 June 1994 the deceased did not leave his cell at the let-go (prisoners vacate cells, which are then checked and locked). The deceased was found hanging in his cell after his absence was noticed.

Issues

The Coroner held that the cell was not checked adequately. He found that this was most probably a result of a misunderstanding between two prison officers. The prison officers were counselled but not disciplined.

The Coroner found various systemic deficiencies with respect to let-gos. First, the quality of cell checks varied greatly despite the training of officers. Secondly, cells contained three places where inmates could hide. Thirdly, officers were unaware of the deceased's suicide risk status. Fourthly, the prisoners in the remand centre were more likely to be suicidal. The remand centre had no work program and prisoners were unsentenced, unsettled and often young. The Governor of the prison indicated that a double check should occur in the Remand Centre.

The Coroner expressed the view that it was desirable to have more Aboriginal people working for Corrective Services, the Police and related government organisations. However, he held that to be a matter for the government, not the Coroner. He also noted the need for counselling of families by Aboriginal organisations.

The Coroner also found no grounds for criticising ambulance officers for the time taken in attending the scene.

Recommendations

1. That sufficient staff be allocated to the Remand Centre, Long Bay Correctional Centre to enable a 'double check' of all cells to be carried out at all 'let go's'.

2. That the existing directive � headed 'Accounting for prisoners at "let go and lock in"' be amended to detail procedure to be adopted by prison officers at each 'let go' to check for inmates who may be hiding in cells at 'let go'.

3. That the system of notifying to individual prison officers that a prisoner may be suicidal /self-harming be reviewed with a view to ensuring that all prison officers entering on duty know the status of such prisoners under their care.

Royal Commission Recommendations Breached

R 152f Guidelines for exchange of information between medical and prison services.

R 152giv Protocols for care and management of Aboriginal prisoners at risk of self-harm.

R 154c Efforts to employ Aboriginal people in prison health services.

R 178 Recruitment of Aboriginal staff to all classifications within Corrective Services

R 184 Ensure opportunities of Aboriginal prisoners for work, training and education, including Aboriginal cultural education.

Social Justice Commissioner

Comment

The Royal Commission recommended that police acting under the Coroner investigate the circumstances of the deceased's incarceration, including the circumstances of arrest or apprehension and the deceased's activities beforehand (R35c). The trend towards the speedier transfer of detainees to prison increases the need for the circumstances of a remandee's arrest and detention be investigated, particularly because a court of law has not investigated the offence charged.

Additional Royal Commission Recommendations Breached

R12 Legal requirement for Coroner to consider how the person was treated before death.

R35 Police investigations should: be approached on the basis that the death may be a homicide; inquire into the arrest or apprehension, lawfulness of custody and treatment and supervision of the deceased; and thoroughly examine the scene of death and forensic exhibits.

R36 Investigations of a death in custody should be structured to provide a thorough evidentiary basis for the coroner.

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67NSW

Male 19, died on 13 December 1994
Parklea Correctional Centre, NSW
Self-inflicted Hanging

Coronial Inquiry John Hiatt, Senior Deputy Coroner.

Finding handed down on 11 August 1995.

Finding

The deceased died a cell at Parklea Correctional Centre from hanging , self-inflicted then and there, with the intention of taking his own life.

Summing Up

Circumstances of death

The deceased was arrested at 11.50pm Friday 9th December while allegedly attempting to break into a motor vehicle. He was taken to Kings Cross Police Station. He was charged with a number of offences at 4.01am Saturday 10th December. Bail was granted, but was not entered. A note was made that the deceased was adversely affected by drugs.

A Prison Admission Form was completed by a Police Officer and forwarded to Parklea Prison. It indicated that the deceased was Aboriginal and a suicide risk. At 11am Saturday 10th December the deceased was admitted to Parklea Prison.

He was interviewed at 5pm by a Drug and Alcohol Worker (DA Worker), who completed the Inmate Contact Screening Form. The inmate contact screening form was designed so that positive responses to questions about self-control, feelings of hopelessness, previous serious suicide attempts or 'suicidal or self-harm thoughts with a well thought out plan' triggered further suicide assessment, presumably by a health professional.

The 'previous attempts' column on the form was ticked. Handwritten notes on the form indicated that the deceased was under the influence of pills and needed to be watched. Although the deceased was recorded as having stated that he was feeling in control, the DA worker noted that this was 'probably due to pills.' The DA Worker recorded a referral to the prison psychologist on the form. The deceased was not marked as 'first time in prison,' as the form was ambiguous. He had previously only been in juvenile detention centres and police cells, and had attempted suicide in a juvenile detention centre.

At 6.30pm the deceased was interviewed by a Registered Nurse. The Corrections Health Reception Health Status Form and the Reception Assessment form completed by the nurse indicated that the deceased had taken '30-40 Rivotril last night' and had attempted suicide twice previously, once aged 13 and once aged 15. The comment on the assessment form was 'Influence - under Benzos' (Benzodiazepines: Valium, etc).

The deceased was taken to the cells by a Senior Wing Officer. The Wing Officer's Information Form was completed by the DA Worker and Nurse. However, neither of them filled in the special supervision requirements. At the inquest they both agreed that they should have recommended the prisoner be placed in a cell with another prisoner. Both the DA Worker and Nurse stated they had verbally communicated this to the Senior Wing Officer. The Wing Officer could not recall such a conversation and there was no entry in the log book entries to this effect.

The deceased went to court on Monday 12 December 1994 and his case was adjourned until Wednesday 14 December 1994. Bail was continued but not entered. The deceased gave the names of potential bailees to the Legal Aid solicitor.

The warrant on which the deceased returned to Parklea CC indicated the deceased was suicidal. Despite the assistance of the Welfare Officer the deceased was unable to obtain bail and was visibly angry about the situation. The psychologist did not see the deceased despite the responses on the reception forms which indicated that a psychological assessment should follow and the two referrals.

At about 4.30am on Wednesday 14 December 1994 prison officers went to the deceased's cell to wake him for court attendance. They found the deceased hanging from a shower rail within the cell. They also found a note from the deceased.

The Coroner found that the above evidence and the post-mortem revealed no suspicious circumstances and that the deceased intentionally took his own life.

Issues

The Coroner held that the deceased should not have been placed in a one out, or even a two out cell. The deceased was young, Aboriginal, was under the influence of drugs, and was in an adult gaol for the first time. He was angry about the fact that bail was not available. He feared the prospect of a prison sentence. The Coroner held that the deceased should have been placed in a clinic cell under observation until medical or psychiatric examination had taken place. The Coroner observed that Royal Commission recommendation 152 was obviously being ignored. He did not find that any known person had prima facie committed an indictable offence but recommended an internal investigation.

The Coroner also expressed concern that:

a. no Aboriginal Welfare Officer, as stipulated by Royal Commission recommendation 174, was available to assist the deceased in obtaining bail;

b. the prison had not complied with Royal Commission recommendation 140 by having cells equipped and maintained with alarm or communication systems;

c. a debriefing did not occur in accordance with Royal Commission recommendation 124;

d. many officers had a limited knowledge of the Royal Commission recommendations despite their adoption by the NSW Government and their purported implementation by the Corrective Services Department and Prison Medical Service; and

e. the evidence of the then Governor of the goal did give the court confidence that anything had changed since the death on 14 December or that persons at the gaol are concerned about the proper implementation of the recommendations of the Royal Commission.

Recommendations

1. The Commissioner of Corrective Services carry out a full inquiry into the circumstances of the assessment and classification of the deceased with a view to taking disciplinary action against persons who have been negligent in respect of those procedures, and such inquiry should focus on the breakdown of communication and failure to put into place appropriate practices and procedures.

2. The Minister investigate the circumstances where recommendations of the Royal Commission into Aboriginal Deaths in Custody adopted by the New South Wales Government have not been properly implemented at Parklea Correctional Centre.

3. The Minister call an inquiry as to whether all Corrective Services, Institutions and Gaols are properly implementing the recommendations of the Royal Commission.

4. The Coroners Court be advised by the Minister within one month of action taken arising out of these recommendations and a copy of the evidence will be forwarded to the Minister at an appropriate time.

Royal Commission Recommendations Breached

R122 Police and custodial authorities to recognise their legal duty of care to persons in their custody.

R123 Instructions on care of persons in custody to be known, understood, enforceable and publicly available.

R124 Debriefing procedures to follow incidents (deaths/medical emergencies) to reduce future risks.

R130 Agreed rules for sharing information between police and corrective service on matters affecting risk.

R140 Installation of alarms or intercom in all cells.

R144 Aboriginal detainees not to be left alone in police cells; place with other Aboriginal persons.

R151 Referral of Aboriginal prisoners/detainees for psychiatric care.

R152f Guidelines for exchange of information between medical and prison services.

R152g(ii) Protocols for care and management of Aboriginal prisoners who have drug related conditions.

R152g(iv) Protocols for the management of prisoners who are at risk of self-harm.

R154a Prison medical services staff to be trained in Aboriginalhealth issues.

R156 Assessment by medical practitioner within 72 hours of reception at prison and referral to psychiatrist where necessary.

R174 Employment and location of Aboriginal Welfare Officer by Corrective Services.

Social Justice Commissioner

Comment

The case indicates that the assessment forms were extremely poorly designed. The 'at risk' indicators were based on self-report. Presumably, many people who were suicidally depressed would not report the fact for fear that they would be prevented from taking their lives. People under the influence of drugs will not usually report that they are depressed until they begin to withdraw. The question about previous imprisonment was ambiguous. As a result, the screening assessment procedure advocated by recommendations 156 and 157 could not be said to have been followed. The forms must be urgently redesigned.

Royal Commission Recommendation 175 suggests that prisons have a short transition period in a custodial setting so that prisoners are able to easily contact relatives and others to make arrangements. The deceased's inability to obtain bail was largely due to his inability to talk to his father.

The Royal Commission also recommended that police acting under the Coroner investigate the circumstances of the deceased's incarceration, including the circumstances of arrest or apprehension and the deceased's activities beforehand (R35c). The trend towards speedier transfer of detainees to prison increases the need for the circumstances of a remandee's detention be investigated, particularly because a court of law has not investigated the charged offence. If the deceased had remained in police custody the circumstances of the arrest would certainly been examined.

Additional Royal Commission Recommendations Breached

R12 Legal requirement for Coroner to consider how the person was treated before death.

R35 Police investigations should: be approached on the basis that the death may be a homicide; inquire into the arrest or apprehension, lawfulness of custody and treatment and supervision of the deceased; and thoroughly examine the scene of death and forensic exhibits.

R36 Investigations of a death in custody should be structured to provide a thorough evidentiary basis for the coroner.

R89 That bail legislation should be revised so that entitlement to bail is recognised in practice.

R95 Where motor vehicle offences are a major factor in imprisonment, programs to be consultatively developed to reduce incidence.

R175 Consideration of a short transition period before entering prison routine.

Response by Minister for Corrective Services

A Board of Inquiry was established consisting of the Principal Legal Officer, Acting Principal Legal Officer, Manager of Classification Operational Support and Chief Executive Officer of Corrections Health Service.

Findings

The Board made the following findings:

Recommendation 1

i. There is no evidence of negligence in respect of the assessment of the deceased when he was received at Parklea correctional Centre.

ii. There was a breakdown of communication whereby the interventions recommended by the screening officers were not actioned. While it had been recommended that the deceased go two-out with another inmate this did not continue when the other inmate was discharged.

iii. The screening of the deceased was conducted within the spirit intended by the Department's procedures.

iv. The need for further development procedures and their implementation has been identified.

v. The examination of all materials indicates that disciplinary proceedings against officers of the Department are unwarranted.

Recommendation 2

i. A number of the recommendations of the Royal Commission into Aboriginal Deaths in Custody have not been fully implemented at Parklea Correctional Centre. These should be the subject of an ongoing Departmental Program.

ii. It is clear that the staff at Parklea Correctional Centre are striving to work within the spirit of the recommendation.

Recommendation 3

i. An assessment has been made of the progress of the Department's effort to implement the Recommendations of the Royal Commission into Aboriginal Deaths in Custody on a statewide basis. While it is apparent that a number of recommendations have been fully implemented there remains a number that are in progress. The Department is committed to developing a comprehensive Aboriginal Action Plan as a matter of priority. This plan will address any outstanding deficiencies in line with the Department's commitment towards full implementation.

Detailed Findings

The Board indicated that the police investigation had been inadequate (if so, a breach of recommendation 35), resulting in findings against the Department of Corrective Services. The Board disagreed with the Coroner on two significant issues. First, they found that the deceased was rightly classified as a low suicide risk as there were no clinical signs of intoxication or withdrawal. They found that police have an exaggerated rating system as police officers are less qualified to identify suicide risk. They therefore agreed with the DA worker and nurse that the appropriate procedure, due to the deceased's drug withdrawal, was a shared cell.

Second, they found that the DA worker and nurse had communicated this need to the Wing Officer, and that the deceased was put into a shared cell until his cell-mate was discharged. They based this finding on additional information they received from interviews with staff. However, the Board found that the nurse and DA worker should nevertheless have completed the form.

The Board therefore found that no negligence had occurred on the part of the DA worker and nurse. They further concluded that no disciplinary action was warranted, particularly given the two inquiries the two officers had already been through.

Social Justice Commissioner Response

Comment

The Board's finding that the Nurse and DA worker found no clinical signs of withdrawal or intoxication seems to contradict the evidence of the DA Worker and the Nurse on the face of the record, and it is doubtful this finding would stand up in court. Apart from the evidence indicated above, the DA worker wrote that the deceased was 'under the influence of pills' (p11) and the Nurse ticked the box for the question 'at time of assessment the inmate appeared to be suffering from: drug effects.'

The Board's inquiry basically made concessions on points which did not indicate specific negligence - the finding that the rostering of psychologists was inadequate is a systemic problem not confined to the facts of this case, and as such could be defended as a resources issue. Factual inconsistencies in the Board's findings indicate problems in the real implementation of recommendation 15, allowing the Coroner to request a response from the Department. In any case, there are grave problems with the notion of asking a department to make a finding that it has itself been negligent.

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71NSW

Male 38, died on 15 February 1995
Broken Hill Gaol, NSW
Natural Causes, Heart Disease

Coronial Inquiry Deputy Coroner John Abernathy

Finding handed down on 7th March 1996.

Finding

The deceased had died of ischaemic heart disease due to calcific coronary atheroscelosis. Diabetes mellitus and pancreatic duct stones were held to be contributing factors.

Summing Up

Circumstances of death

The deceased was on remand at Broken Hill Prison for a homicide offence. He had arrived there on 31 August 1994.

On Wednesday 15 February 1995 the deceased complained of stomach pains, and was taken to see a nurse at about 6.10pm. He was treated with Mylanta, observed for a short time and shortly after he was reported to have stated that he was feeling fine. He was returned to his cell by a Prison Officer at about 6.45pm.

The Officer next saw the deceased about 7.20pm after being alerted by an inmate. Help was summoned and CPR commenced by two prisoners, one of whom was a relative of the deceased. An ambulance was summoned by prison officers and the family was notified by the relative of the deceased.

Issues

The Coroner was satisfied with the conduct of prison and police officers but raised a number of concerns in response to submissions from the family.

The Coroner considered the adequacy of health assessment procedures. The family submitted that a medical practitioner should assess freshly received prisoners in accordance with Royal Commission recommendation 156.

The Coroner held that assessment by a Registered Nurse, which the Coroner understood to be the practice of most NSW prisons, was sufficient. The Coroner did, however, recommend that the health assessment form be amended to focus on symptoms rather than just history of disease.

The Coroner also recommended that an 'air viva' device, an apparatus which supplements or takes the place of mouth to mouth resuscitation, be widely available to trained prison officers and prisoners. This recommendation is consistent with Royal Commission recommendation 159. The Coroner did not hold that the availability of such a device would have prevented the death.

The family held doubts as to the identity of the body buried at Wilcannia. The Coroner found that the confusion arose from the identification process being conducted after the performance of a second autopsy, which leads to significant changes in appearance. The Coroner held that identification should have occurred before the first autopsy, although he gave no reason why this did not occur. However, he rejected the submission that the autopsy should have been conducted in Broken Hill, to avoid identification problems, on the basis that full-time forensic pathologists are only available in Sydney. He also rejected the submission that dental records should be routinely used for identification since they are unnecessary in most cases. Satisfied by the evidence of identification he also rejected the submission for exhumation of the body. However, the Coroner recommended that seminars be organised for Aboriginal people involved in inquests, prison, police and health officials on topics, suggested by the families, which included viewing before autopsy, return of the body and changes to bodies following post mortems.

Recommendations

1. That the Corrections Health Service revises the Health Reception Assessment form by including questions which focus on symptoms and signs of heart disease.

2. That 'air viva' devices be widely available in prisons for the use of those prison officers and prisoners trained in first aid.

3. That the New South Wales Government through an appropriate instrumentality such as T.A.F.E. or the Department of Health, give consideration to the holding of occasional specifically designed seminars. Such seminars should be aimed at educating those involved in notifying and in generally assisting recently bereaved next of kin of Aboriginal prisoners who die in custody.

Royal Commission Recommendations Breached

R 159 All prisons and watch-houses should have resuscitation equipment

Social Justice Commissioner

Comment

The Coroners recommendation that the Health Reception Form include questions on symptoms is welcomed. However, assessment by a nurse is not consistent with recommendation 156. The recommendation is clear: prisoners are to be assessed by a medical practitioner within 72 hours of admission if initially assessed by a nurse.

The Coroner's summary leaves doubt as to whether the Prison Officer was trained in resuscitation procedures as required by Recommendation 160.

Confusion over identification procedures could have been avoided through implementation of Recommendation 38. This calls for a protocol to be developed between the Coroner, ALS and Aboriginal Health Services to avoid confusion and conflict over autopsies and traditional rites.

Deputy Coroner Abernathy displays a large degree of awareness of, and sensitivity to, the RCIADIC recommendations. He also provides useful comments on the case in addition to the formal finding.

Additional Royal Commission Recommendations Breached

R38 State Coroner should develop protocol for inquiries, autopsies and burial.

R156 Assessment by medical practitioner within 72 hours of reception at prison.

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72NSW Male 20, died on 1 March 1995
Long Bay Prison, NSW
Self-Inflicted Hanging

Coronial Inquiry Deputy State Coroner John Abernathy

Finding handed down on 7 November 1995

Finding

The deceased died when he hanged himself, but not with the intention to kill himself.

Summing Up

Circumstances of death

The deceased was received into the Remand Centre on 14 February 1995. He was awaiting trial for the offence of break and enter. He was not considered suicidal but was placed 'two out' - a cell with another prisoner. On 21 February 1995 he attempted suicide by hanging but was held up by a cell mate. He was angry, hostile and complained of being beaten by other inmates. He was placed in a safe cell under strict protection.

On 22 February he was seen by the Crisis Intervention Team who assessed him as settled. Later that day, however, he cut the tendons of his left wrist and was admitted to the Prince of Wales Hospital for surgery. A psychiatrist at the hospital assessed the deceased as a high suicide risk and wrote to the Corrections Health Service and spoke to the psychiatric registrar at Long Bay about the deceased.

The deceased was returned to psychiatry ward 'B' at Long Bay. He was assessed by medical practitioners as having a personality disorder but not currently suicidal.

On 24 February he was placed in a normal cell in the Psychiatry Unit. He was extremely abusive of staff on 1 March 1995 and was locked in his own cell in seclusion. He was seen tampering with the window and was placed in a 'safe cell'. He was later placed back in his own cell when other suicidal prisoners needed to be placed in safe cells. He was seen by the psychiatric registrar early in the afternoon, who assessed the deceased as angry but not suicidal.

The deceased was subsequently found hanging in his cell when prison officers checked him at 6.05pm.

Issues

The Coroner found nothing in the actions of the Department of Corrective Services and its officers that would warrant criticism. He found that the prior suicide attempts were not serious. The first attempt occurred with another prisoner in the cell who held him up. The deceased stated to the psychiatric registrar that he didn't believe his second attempt would kill him and he let himself bleed before he rang the buzzer.

The Coroner, however, expressed concern at the care for the deceased when he was held in seclusion. Observations were only half hourly and notation was not made of them. The Coroner noted that a new protocol was now in existence. The protocol: (i) sets out circumstances when seclusion is appropriate; (ii) requires discussion with, and counselling of, patients; (iii) seclusion as at the nurse's discretion (iv) there is a maximum of four hours seclusion with 15 minute observations; and (v) notation of all of the above.

The Coroner commented that the number of 'safe cells' was possibly insufficient. He also stated that appropriate documentation and reassessment of the patient was required on transfer between a safe cell and normal cell.

The family submitted that the deceased may have met with foul play. The deceased had expressed fears for his life after apparently receiving threats from other prisoners. The Coroner found that more evidence was required for him to make such a finding since the cell was locked and the post mortem examination showed no interference.

The Coroner lastly considered various recommendations of the Royal Commission. He found compliance with recommendation 151 since the resident psychiatrist had sufficient experience with Aboriginal people. However, he found that there was insufficient compliance with recommendation 154. This recommendation requires education of prison medical staff in Aboriginal history, culture and life-style and the need for consultation with relevant Aboriginal organisations. The Coroner found that had staff known of the deceased's Aboriginality, and had there been an Aboriginal welfare officer, then an Aboriginal health worker might have been called to resolve the issue. The Coroner also called for a review of health services including development of protocols dealing with action to be taken in the care of apparently angry, aggressive or disturbed persons under Recommendation 152(g)(v).

The Coroner concluded that the prisoner was not suicidal but accidentally hanged himself. The deceased's fear of beatings on return to prison may have precipitated the hanging attempt to maintain his classification in the psychiatry ward.

Recommendations

1. That the moving of a prisoner from safe cell to another cell be noted and that before such a prisoner is moved, that he be fully reassessed by nursing staff responsible for moving him from the safe cell.

2. That all staff of the Corrections Health Service who handle Aboriginal prisoners be educated, as a matter of priority, on relevant issues of Aboriginality.

3. That Recommendation 152(g)(v) of the Aboriginal Deaths in Custody Commission be implemented by the Corrections Health Services as quickly as possible.

Royal Commission Recommendations Breached

R137 Specified intervals between checks on the health and safety of detainees

R152c AHS involvement in review of prison medical services.

R152g(v) Protocols for care and management of Aboriginal prisoners who are angry.

R154a Prison medical services staff to be trained in Aboriginal history, culture and lifestyle.

R154b Consultation with AHS on informing and training medical staff.

R154c Efforts to employ Aboriginal people in prison health services.

R174 Employment and location of Aboriginal Welfare Officer by Corrective Services

Social Justice Commissioner

Comment

The Coroner's acceptance of the psychiatrists conclusion as to the deceased's low risk status is questionable. The deceased was clearly not coping in his first week in the Remand Centre. He had attempted suicide twice, was angry and hostile and afraid of other inmates. Alternative explanations for the deceased's admission as the non-seriousness of the two previous attempts, such as to save face or leave the way clear for later attempts, were not considered.

In any case, the two suicide attempts and subsequent behaviour should have resulted in the deceased being treated at minimum as a moderate suicide risk with frequent or constant observation and a relatively safe cell.

The case bears similarities to the Aboriginal man who died in Risdon Prison in 1991 (30TAS) in the deceased was afraid of returning to the main prison and committed suicide after being downgraded to a low suicide risk in the prison hospital.

This death was the third death from suicide of a young Aboriginal man in a NSW remand centre within nine months. In all cases the deceased were not coping with prison life. This case also demonstrates the need for a transition period consistent with Royal Commission recommendation 175 to allow remandees and prisoners to communicate with their families and ease emotional trauma, and to make necessary personal and legal arrangements.

Additional Royal Commission Recommendations Breached

R152g(iv) Protocols for care and management of Aboriginal prisoners at risk of self-harm.

R175 Consideration of a short transition period before entering prison routine.

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75NSW

Male 52, died on 21 April 1995
Cooma Hospital, ex Cooma Prison, NSW
Natural Causes, Heart Attack

Coronial Inquiry Deputy State Coroner John Abernathy

Finding handed down on 14 November 1995

Finding

The deceased died at Cooma District Hospital of atherosclerotic cardiovascular disease.

Summing Up

Circumstances of death

The deceased was serving a minimum of three and half years for sex offences at Cooma Prison. He was an elder in his community, a 'model' prisoner and a teacher in the prison.

The deceased had told a doctor and nurse of several prior strokes and angina. On 22 August 1994 he complained to the doctor of chest pains. There was no ECG machine in Cooma and he was referred to Sydney. The deceased, however, signed a statement on 31 August stating he did not wish to be transferred. He was subsequently seen for various ailments over the following months but none of these appeared to be related to his cardiovascular system. On 20 April 1995 he complained of pains in his legs. He collapsed at breakfast at 6.45 am the following day. The nurse attempted resuscitation and called for an oxy viva and ambulance. He was pronounced dead at 8.04am.

Issues

The Coroner found nothing to criticise in the actions of prison or nursing staff or ambulance officers. There was a slight delay in the arrival of the ambulance and the battery in the defibulator was flat. The Coroner, however, found that this had no significant impact. The Coroner also found that the decision of the nurse not to move the deceased but wait for the ambulance to be correct.

The Coroner declined from making a recommendation that prisoners be allowed accommodation in the ACT so they can receive treatment at Woden Valley Hospital. There is no prison in the ACT, and the Remand Centre presently has no facilities for holding prisoners on protection.

The Coroner considered the fear of transfer held by Cooma prisoners. They feared violence at the hands of inmates in Sydney because they are sex offenders. The Coroner accepted evidence that sex offenders are sufficiently protected on visits to Long Bay Prison. However, he informally recommended that Cooma Prison check the level of protection at Long Bay Prison. He also recommended that the Cooma Prison administration diligently counsel prisoners as to the safety of transfer and that prisoners who make the journey to Sydney be requested to speak to other prisoners about the experience.

Recommendations See discussion above.

Royal Commission Recommendations Breached Nil

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76NSW

Male 54, died on 23 June 1995
Police Custody, Deniliquin, NSW
Head Injury

Coronial Inquiry Kenneth Smith SM

Finding handed down on 28 August 1995

Finding

The deceased, on 23 June 1995, on an unmarked gravel road which leads to the Moama Beach, and beneath the Moama to Echuca Bridge at Moama in the State of New South Wales, died of severe internal haemorrhage and other associated injuries sustained there and then, following a fall from that bridge onto the roadway.

Summing Up

Circumstances of Death

The deceased attended the premises of his previous de facto partner in Moama shortly after 9.30pm Friday 23 June 1995. He did so in breach of a domestic violence order. He assaulted her, and she ran to the police station. A search was made of the area by Moama and Echuca Police but the deceased could not be located.

At 10.50pm that evening a police sergeant drove across the Moama/Echuca bridge and sighted the deceased crossing the bridge. The deceased and the police sergeant made eye contact. The sergeant drove across the bridge, made a U-turn and returned to the bridge. He subsequently sighted the deceased lying on his back directly below the bridge. Police attended the location and called ambulance. He was still alive with a pulse when police arrived. He died a short time later and CPR was attempted without success.

Issues

The Coroner found that this case was not a death in custody. He also declined from stating whether the fall was accidental or intentional on the part of the deceased. The deceased had a high blood alcohol reading and had taken some serapax but had a high tolerance of alcohol.

Recommendations Nil

Royal Commission Recommendations Breached Nil

Social Justice Commissioner

Comment

This case is clearly a death in custody. Recommendation 6c states that deaths in custody include: 'the death wherever occurring of a person who dies or is fatally injured in the process of police or prison officers attempting to detain that person.' In this case police were searching for the deceased. The deceased and the sergeant made eye contact and identified one another. The deceased knew the sergeant from previous dealings. The deceased would have heard the police vehicle slow down and possibly turn.

Communication with the Coroner indicated that he and the State Coroner believed a case such as this did not warrant the effort of a full coronial inquest. This case, however, does demonstrate the need for such an inquest. Suspicions remain about the circumstances of the death. The incident occurred in a remote location and only police and the deceased were involved. Police and the deceased's previous partner were the only witnesses at the hearing and they were not cross-examined.

The NSW State Deputy Coroner John Abernathy's comment is relevant: 'It may seem to observers that a comprehensive inquest in a case such as this is unnecessary. A little reflection ought to indicate however, that such a proceeding is in fact, very necessary. Since the Royal Commission into Aboriginal Deaths in Custody, a determined effort has been made by successive governments in this state to attempt to eradicate such incidents'. 9

The case also revealed that police did not have resuscitation training and equipment in accordance with recommendation 160. CPR was only commenced when ambulance officers arrived. Coroner Hiatt had recommended that police officers be trained and have equipment in their vehicles on 31 March 1994.

Additional Royal Commission Recommendations Breached

R6c Deaths in custody 'to include deaths occurring in the process of police or prison officers attempting to detain that person.'

R12 Legal requirement for Coroner to consider how the person was treated before death

R159 Availability of safe, effective resuscitation equipment and trained staff in all prisons and watch houses.

R160 Basic training for all police and prison officers in revival techniques with annual first aid refresher courses.

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80NSW

Male 18, died on 26 July 1995
Cobbs Rd, Tuggerah, NSW
Injuries in Car Accident, Police Pursuit

Coronial Inquiry Inquest not commenced

Social Justice Commissioner

Comment

Newspaper reports indicate that the deceased with two other male persons (one of whom also died) stole a car from Marrickville on the afternoon of Monday 25 July 1995. A police pursuit began at 2.15am Tuesday 26 July 1995 in Maitland. Police commenced pursuit after being notified by a driver through the triple-0 emergency number. Maitland police pursued for a few minutes but then lost sight of the car as they slowed to a safer speed.

Wyong police located the car at Wyee about 30 minutes later. They commenced pursuit. The stolen car attempted to overtake the police and in avoiding a semi-trailer mounted the median strip, nosedived and then rolled several times. The occupants, who were not wearing seatbelts, were thrown from the car.

The deceased was conveyed by air to John Hunter Hospital. He was pronounced life extinct at 4.35am.

This case clearly raises the question of the necessity of the Wyong Police in recommencing pursuit.

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81NSW

Male 17, died on 26 July 1995
Cobbs Rd, Tuggerah, NSW
Injuries in Car Accident, Police Pursuit

Coronial Inquiry Inquest not commenced

Social Justice Commissioner

Comment

See case profile (80NSW) above for a description of events leading to the car crash as reported by newspapers. The deceased was conveyed to Gosford Hospital where he died some hours later.

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83NSW

Male 44, died on 29 September 1995
Long Bay Remand Centre, NSW
Natural Causes

Coronial Inquiry Inquest not commenced

Social Justice Commissioner

Comment

The deceased was an inmate at Long Bay Remand Centre since 4/7/95 on a charge of 'sexual assault' and 'use of weapon'. The deceased died in his cell during the early morning of 29 September 1995 from unknown natural causes.

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87NSW Male 22, died on 23 November 1995
Goulburn Prison, NSW
Injury, Bashing

Coronial Inquiry Inquest not commenced

Social Justice Commissioner

Comment

The deceased was serving four years imprisonment for burglary offences. The Department of Corrective Services stated that he suffered severe head injuries in a fight involving up to six other inmates at Goulburn maximum security prison on 16 November 1995. He died 7 days later in the Prince of Wales Hospital.

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91NSW

Male 47, died on 7 January 1996
Junee Prison, NSW
Natural Causes

Coronial Inquiry Inquest not commenced.

Social Justice Commissioner

Comment

A spokesman for the Corrective Services Department said the deceased collapsed at 7.10am after carrying out his usual work duties. 10 He was pronounced dead at 9am, despite efforts to revive him. This is the first Aboriginal death at the private Junee prison.

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92NSW

Male 25, died on 13 February 1996
Goulbourn Prison, NSW
Injury, Stabbing

Coronial Inquiry

A known person was charged with an indictable offence in relation to the death and the holding of an inquest was 'terminated under Section 19' on the 22 May 1996.

The post-mortem report found the cause of death as stab wounds of neck and chest.

Social Justice Commissioner

Comment

NSW Corrective Services regional commander stated that the deceased was stabbed several times. He managed to crawl to the end of the yard where he was spotted by prison warders who summoned a doctor. 11 He was treated at the jail but died in an ambulance on the way to Goulburn Base Hospital. The NSW Aboriginal Deaths in Custody Watch Committee stated that the deceased had been in juvenile centre or adult prisons since the age of 14. 12

The current practice of NSW Coroners not to investigate such deaths for the purpose of preventing deaths in similar situations (see 40NSW for example) is disappointing given he preventative nature of the Royal Commission recommendations concerning coroners.

Additional Royal Commission Recommendations Breached

R11 Legal requirement for public coronial inquiry into all deaths in custody.

R12 Legal requirement for Coroner to consider how the person was treated before death.

R13 Coroner to recommend ways to prevent further deaths.


ENDNOTES 

1 R. Macey, 'Car crash led to death in cell', Sydney Morning Herald ,1/6/90 at p.5.

2
Simon Eyland, Truth in Sentencing: A Koori Perspective (Unpublished paper) at p.49.

3 This section is taken from the transcript since the coroner did not provide a summing-up.

4
Summarised from p.17 of the summing-up.

5
National Report, Volume 4 p.223.

6
RCIADIC, National Report, Vol 1, p118.

7
Police vehicles do not strictly meet this definition but the Coroner's view is in line with the spirit of the recommendation.

8
This section is largely taken from the transcript since the Coroner did not provide a summing-up.

9
Inquest 307 of 1995 at p.1 (Case 72NSW)

10 The Age Newspaper, 8 January 1996.

11
Steven Corby, Canberra Times, 14 February 1996, p.2.

12
Media Release, 14th February 1996.